Provider Demographics
NPI:1528167996
Name:MCCANN, MICHAEL LAWWELL (DO)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:LAWWELL
Last Name:MCCANN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 12358
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30914-2358
Mailing Address - Country:US
Mailing Address - Phone:706-863-9595
Mailing Address - Fax:706-868-8375
Practice Address - Street 1:3100 CHANNING WAY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7533
Practice Address - Country:US
Practice Address - Phone:706-863-9595
Practice Address - Fax:706-868-8375
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDOC-0063208600000X, 2086S0102X
COCDRH.00609892086S0102X
FLOS141552086S0102X
GA854762086S0102X
MI51010142492086S0102X
MN489732086S0102X
WY12672C2086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200573200AMedicaid
MI5250354OtherBLUE CROSS PIN
MI1528167996Medicaid
KSP00628712OtherRR MEDICARE
KSP00628712OtherRR MEDICARE
KS068002024Medicare PIN